Effectiveness of a tailor-made weight loss intervention in primary care

Weight Management Interventions Provided by a Dietitian for Adults with Overweight or Obesity: An Evidence Analysis Center Systematic Review and Meta-Analysis

BACKGROUND

Obesity is associated with a multitude of comorbidities and considerable health care costs.

OBJECTIVE

The objective of this review was to examine the efficacy of weight management interventions provided by a registered dietitian or international equivalent (referred to as "dietitian").

METHODS

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the effect of weight management interventions provided by a dietitian, compared with usual care or no intervention, on several cardiometabolic outcomes and quality of life in adults with overweight or obesity. MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for eligible RCTs published between January 2008 and January 2021 in the English language. Meta-analyses were conducted using a random-effects model, publication bias was assessed using funnel plots and Egger's statistics, and heterogeneity was assessed by interpreting I2 values. Efficacy of intervention components, such as telehealth or group contacts, were explored in sub-group analyses. Version 2 of the risk-of-bias tool for RCTs was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation method was used to determine certainty of evidence.

RESULTS

This systematic review included 62 RCTs. Compared with control conditions, weight management interventions provided by a dietitian resulted in improved body mass index (mean difference [MD] -1.5; 95% CI -1.74 to -1.26; moderate evidence certainty); percent weight loss (MD -4.01%; 95% CI -5.26% to -2.75%; high evidence certainty); waist circumference (MD -3.45 cm; 95% CI -4.39 to -2.51 cm; high evidence certainty); blood pressure (MD -3.04 mm Hg; 95% CI -5.10 to -0.98 mm Hg and MD -1.99 mm Hg; 95% CI -3.02 to -0.96 mm Hg for systolic blood pressure and diastolic blood pressure, respectively; moderate and low evidence certainty); and quality of life using the 36-Item Short Form Survey (MD 5.84; 95% CI 2.27 to 9.41 and 2.39; 95% CI 1.55 to 3.23 for physical and mental quality of life, respectively; low and moderate evidence certainty).

CONCLUSIONS

For adults with overweight or obesity, weight management interventions provided by a dietitian are efficacious for improving several examined cardiometabolic outcomes and quality of life.

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.

Nutritional intervention strategies for the management of overweight and obesity in primary health care: A systematic review with meta-analysis

A systematic review with meta-analysis (MA) was conducted to synthesize the effectiveness of nutrition intervention strategies for managing overweight and obesity in the adult population attending primary health care. Relevant articles were searched in the PubMed, Embase, Web of Science, Cochrane and LILACS databases from inception to January 2020. Seventy studies were identified: 45 randomized controlled trials (RCTs) and 25 uncontrolled before-after studies (UBAs). The MA of nutritional intervention revealed a reduced average estimate of the effect on weight in RCTs (weighted mean differences [WMD] = -1.80 kg, 95% confidence interval [CI], -2.40 to -1.19), BMI (WMD = -0.80 kg/m² , 95% CI, -1.11 to -0.49), and WC (WMD = -2.28 cm, 95% CI, -3.06 to -1.49); and for UBAs showed reductions in weight (WMD = -4.17 kg; 95% CI, -5.18 to -1.70), BMI (WMD = -1.26 kg/m² ; 95% CI, -1.81 to -0.72) and (WMD = -2.90 cm; 95%CI, -4.21 to -1.59). There was no association between treatment effect and follow-up for both designs. Nutritional interventions alone yielded a higher but nonsignificant average reduction on weight when compared with combined components intervention. Interventions delivered through individual or group sessions showed a similar positive effect on weight decrease. The dietary prescription approach yielded a greater effect on weight loss than did the behavioural approaches but only in UBA studies.

Team-based "Get-a-Grip" lifestyle management programme in the treatment of obesity

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Team-based one-year lifestyle programme led to mean weight loss of 4.8 kg.

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Among the participants 44% lost ≥ 5%, while 21% lost ≥ 10% of their initial weight.

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Beneficial changes were detected in muscle mass, body fat, and visceral fat.

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Systolic and diastolic blood pressure was reduced significantly.

This study examined weight loss during an extensive 1-year lifestyle programme in primary care in Finland in overweight subjects (n = 134, age 18–69 years; BMI > 30, or BMI > 25 with a comorbidity that would benefit from weight loss) between 2009 and 2013 in a single arm design. The programme included four medical doctor visits, five sessions by a dietitian (advice on diet and on-location shopping behaviour), cooking classes, exercise supervised by personal trainer, and group discussions. A motivational interview method was applied.

Of the 134 participants, 92 (69%) completed the 1-year programme. Among the participants 44% lost ≥ 5%, while 21% lost ≥ 10% of their initial body weight. In intention-to-treat-analyses, the mean weight loss during one year was 4.8 kg (p < 0.001). Mean BMI decreased by 1.7 kg/m² (p < 0.001) and waist circumference by 5.6 cm (p < 0.001). Mean muscle mass increased by 3.3% (p < 0.001), and body fat decreased by 5.0% (p < 0.001). After the programme mean visceral fat content was reduced by 6.4%, systolic blood pressure by 8 mmHg (p < 0.001), and diastolic blood pressure by 6 mmHg (p < 0.001).

In conclusion, retention to the team-based lifestyle management programme resulted in moderate but significant weight loss with beneficial changes in body composition, and the trend to lose weight was maintained throughout the year.

Trial registration: Clinicaltrials.gov identifier NCT04003259.

Effect of weight change on progression of knee OA structural features assessed by MRI in overweight and obese women

OBJECTIVE

To evaluate the effects of weight change on progression of knee osteoarthritis (OA) structural features by magnetic resonance imaging (MRI) in overweight and obese women without clinical knee OA.

DESIGN

347 participants from the Prevention of Knee Osteoarthritis in Overweight Females (PROOF) study were classified with latent class growth analysis into a subgroup with steady weight (n = 260; +0.1 ± 4.0 kg, +0.2 ± 4.4%), weight gain (n = 43; +8.6 ± 4.0 kg, +9.8 ± 4.1%) or weight loss (n = 44; -9.0 ± 7.2 kg, -9.8 ± 7.5%) over 2.5 years. Baseline and follow-up 1.5T MRIs were scored with MRI Osteoarthritis Knee Score (MOAKS) for progression of bone marrow lesions (BMLs), cartilage defects, osteophytes, meniscal abnormalities, meniscal extrusion and synovitis. Associations between subgroups and change in MRI features at knee-level were assessed using adjusted Generalized Estimating Equations.

RESULTS

687 knees from 347 women (median age 55.2 years, interquartile range (IQR) 5.5, median body mass index (BMI) 31.2 kg/m², IQR 5.3) were analyzed. Progression of synovitis was 18% in the weight gain vs 7% in the stable weight subgroup (OR 2.88; 95%CI 1.39-5.94). The odds for progression of patellofemoral (PF) BMLs and cartilage defects increased with 62% (OR 1.62; 95%CI 0.92-2.84) and 53% (OR 1.53; 95%CI 0.92-2.56) in the weight gain vs the stable weight subgroup.

CONCLUSIONS

In overweight and obese women, progression of synovitis increased more than 2.5 times in a weight gain compared to a stable weight subgroup over 2.5 years. Large effect sizes were also found for the difference in progression of PF BMLs and PF cartilage defects between the weight gain and stable weight subgroup.

Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Overweight and obesity have been associated with adverse health effects.

OBJECTIVE

To systematically review evidence on benefits and harms of behavioral and pharmacotherapy weight loss and weight loss maintenance interventions in adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed Publisher-Supplied Records, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 6, 2017; ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials through August 2017; and ongoing surveillance in targeted publications through March 23, 2018. Studies from previous reviews were reevaluated for inclusion.

STUDY SELECTION

Randomized clinical trials (RCTs) focusing on weight loss or weight loss maintenance in adults.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted by one reviewer and confirmed by another. Random-effects meta-analyses were conducted for weight loss outcomes in behavior-based interventions.

MAIN OUTCOMES AND MEASURES

Health outcomes, weight loss or weight loss maintenance, reduction in obesity-related conditions, and adverse events.

RESULTS

A total of 122 RCTs (N = 62 533) and 2 observational studies (N = 209 993) were identified. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months (-2.39 kg [95% CI, -2.86 to -1.93]; 67 studies [n = 22065]) and less weight regain (-1.59 kg [95% CI, -2.38 to -0.79]; 8 studies [n = 1408]). Studies of medication-based weight loss and maintenance interventions also reported greater weight loss or less weight regain in intervention compared with placebo groups at 12 to 18 months (range, -0.6 to -5.8 kg; no meta-analysis). Participants with prediabetes in weight loss interventions had a lower risk of developing diabetes compared with controls (relative risk, 0.67 [95% CI, 0.51 to 0.89]). There was no evidence of other benefits, but most health outcomes such as mortality, cardiovascular disease, and cancer were infrequently reported. Small improvements in quality of life in some medication trials were noted but were of unclear clinical significance. There was no evidence of harm such as cardiovascular disease from behavior-based interventions; higher rates of adverse events were associated with higher dropout rates in medication groups than in placebo groups.

CONCLUSIONS AND RELEVANCE

Behavior-based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms. Long-term weight and health outcomes data, as well as data on important subgroups, were limited.

Evaluating the impact of a home-based rehabilitation service on older people and their caregivers: a matched-control quasi-experimental study

Introduction

Previous studies evaluating home-based rehabilitation service (HBRS) merely focused on the period immediately after the patients’ discharge from hospitals. The present study focuses on HBRS that covers clients who have not been recently hospitalized. HBRS aims to meet older clients’ rehabilitation needs and support their caregivers in the community. This study intended to evaluate the impact of HBRS on the older clients’ health outcomes and hospital services utilization, and caregivers’ strain in providing care for clients.

Methods

This study used a matched-control quasi-experimental design with a 3-month follow-up to evaluate HBRS. The health outcome measures used for the older clients included Elderly Mobility Scale, Timed Up and Go test, Modified Barthel Index, Lawton’s Instrumental Activities of Daily Living Scale, Mini-Mental State Examination, and World Health Organization Quality of Life Scale, Short Form, Hong Kong version (WHOQOL-BREF [HK]). Meanwhile, the Caregiver Strain Index was used to measure the caregivers’ caregiving strain. Data on clients’ hospital services utilization 3 and 6 months before and after the study were also collected and evaluated.

Results

The final sample consisted of 122 pairs of older clients and caregivers who live in a community in Hong Kong. In the follow-up after 3 months, the intervention group showed immensely substantial improvements across all the health outcome measures compared with the control group. The intervention group also demonstrated substantial reduction in the clients’ hospital services utilization compared with the control group. However, no significant differences in the clients’ hospital services utilization exist between the two groups in the follow-up after 6 months.

Conclusion

HBRS of this study is an effective intervention service to improve health outcomes and reduce hospital services utilization among older people living in the community. Moreover, HBRS of this study was effective in reducing the caregivers’ caregiving strain.

Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: a mixed methods systematic review

Worldwide prevalence of adult overweight and obesity is a growing public health issue. Adults with overweight/obesity often have chronic musculoskeletal pain. Using a mixed-methods review, we aimed to quantify the effectiveness and explore the appropriateness of weight loss interventions for this population. Electronic databases were searched for studies published between 01/01/90 and 01/07/16. The review included 14 randomized controlled trials that reported weight and pain outcomes and three qualitative studies that explored perceptions of adults with co-existing overweight/obesity and chronic musculoskeletal pain. The random-effects pooled mean weight loss was 4.9 kg (95%CI:2.9,6.8) greater for intervention vs control. The pooled mean reduction in pain was 7.3/100 units (95%CI:4.1,10.5) greater for intervention vs control. Study heterogeneity was substantial for weight loss (I²  = 95%, tau = ±3.5 kg) and pain change (I²  = 67%, tau = ±4.1%). Meta-regression slopes for the predictors of study quality, mean age and baseline mean weight on mean study weight reduction were shallow and not statistically significant (P > 0.05). The meta-regression slope between mean pain reduction and mean weight lost was shallow, and not statistically significant, -0.09 kg per unit pain score change (95%CI:-0.21,0.40, P = 0.54). Meta-synthesis of qualitative findings resulted in two synthesized findings; the importance of healthcare professionals understanding the effects of pain on ability to control weight and developing management/education programmes that address comorbidity.

Effects of weight loss interventions for adults who are obese on mortality, cardiovascular disease, and cancer: systematic review and meta-analysis

Objective To assess whether weight loss interventions for adults with obesity affect all cause, cardiovascular, and cancer mortality, cardiovascular disease, cancer, and body weight.Design Systematic review and meta-analysis of randomised controlled trials (RCTs) using random effects, estimating risk ratios, and mean differences. Heterogeneity investigated using Cochran's Q and I² statistics. Quality of evidence assessed by GRADE criteria.Data sources Medline, Embase, the Cochrane Central Register of Controlled Trials, and full texts in our trials' registry for data not evident in databases. Authors were contacted for unpublished data.Eligibility criteria for selecting studies RCTs of dietary interventions targeting weight loss, with or without exercise advice or programmes, for adults with obesity and follow-up ≥1 year.Results 54 RCTs with 30 206 participants were identified. All but one trial evaluated low fat, weight reducing diets. For the primary outcome, high quality evidence showed that weight loss interventions decrease all cause mortality (34 trials, 685 events; risk ratio 0.82, 95% confidence interval 0.71 to 0.95), with six fewer deaths per 1000 participants (95% confidence interval two to 10). For other primary outcomes moderate quality evidence showed an effect on cardiovascular mortality (eight trials, 134 events; risk ratio 0.93, 95% confidence interval 0.67 to 1.31), and very low quality evidence showed an effect on cancer mortality (eight trials, 34 events; risk ratio 0.58, 95% confidence interval 0.30 to 1.11). Twenty four trials (15 176 participants) reported high quality evidence on participants developing new cardiovascular events (1043 events; risk ratio 0.93, 95% confidence interval 0.83 to 1.04). Nineteen trials (6330 participants) provided very low quality evidence on participants developing new cancers (103 events; risk ratio 0.92, 95% confidence interval 0.63 to 1.36).Conclusions Weight reducing diets, usually low in fat and saturated fat, with or without exercise advice or programmes, may reduce premature all cause mortality in adults with obesity.Systematic review registration PROSPERO CRD42016033217.

Weight-loss and exercise for communities with arthritis in North Carolina (we-can): design and rationale of a pragmatic, assessor-blinded, randomized controlled trial

BACKGROUND

Recently, we determined that in a rigorously monitored environment an intensive diet-induced weight loss of 10% combined with exercise was significantly more effective at reducing pain in men and women with symptomatic knee osteoarthritis (OA) than either intervention alone. Compared to previous long-term weight loss and exercise trials of knee OA, our intensive diet-induced weight loss and exercise intervention was twice as effective at reducing pain intensity. Whether these results can be generalized to less intensively monitored cohorts is unknown. Thus, the policy relevant and clinically important question is: Can we adapt this successful solution to a pervasive public health problem in real-world clinical and community settings? This study aims to develop a systematic, practical, cost-effective diet-induced weight loss and exercise intervention implemented in community settings and to determine its effectiveness in reducing pain and improving other clinical outcomes in persons with knee OA.

METHODS/DESIGN

This is a Phase III, pragmatic, assessor-blinded, randomized controlled trial. Participants will include 820 ambulatory, community-dwelling, overweight and obese (BMI ≥ 27 kg/m2) men and women aged ≥ 50 years who meet the American College of Rheumatology clinical criteria for knee OA. The primary aim is to determine whether a community-based 18-month diet-induced weight loss and exercise intervention based on social cognitive theory and implemented in three North Carolina counties with diverse residential (from urban to rural) and socioeconomic composition significantly decreases knee pain in overweight and obese adults with knee OA relative to a nutrition and health attention control group. Secondary aims will determine whether this intervention improves self-reported function, health-related quality of life, mobility, and is cost-effective.

DISCUSSION

Many physicians who treat people with knee OA have no practical means to implement weight loss and exercise treatments as recommended by numerous OA treatment guidelines. This study will establish the effectiveness of a community program that will serve as a blueprint and exemplar for clinicians and public health officials in urban and rural communities to implement a diet-induced weight loss and exercise program designed to reduce knee pain and improve other clinical outcomes in overweight and obese adults with knee OA.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02577549 October 12, 2015.

Prevention of Incident Knee Osteoarthritis by Moderate Weight Loss in Overweight and Obese Females

OBJECTIVE

This study evaluated the effect of moderate weight loss on the incidence of knee osteoarthritis (OA) in middle-aged overweight and obese women, without clinical and radiologic knee OA at baseline.

METHODS

A total of 353 women (87%) with followup data available were selected from the Prevention of Knee Osteoarthritis in Overweight Females study, which evaluated the preventive effect of a diet and exercise intervention and of oral glucosamine sulfate on the incidence of knee OA. This was an exploratory proof-of-concept analysis, which compared the incidence of knee OA between women who reached the clinically relevant weight loss target of 5 kg or 5% of body weight after 30 months and those who did not reach this target.

RESULTS

The weight loss group showed a significantly lower incidence of knee OA according to the primary outcome measure, which was composed of the American College of Rheumatology criteria (clinical and radiographic), Kellgren/Lawrence grade ≥2, and joint space narrowing ≥1.0 mm (15% versus 20%; odds ratio 0.5, 95% confidence interval 0.3-0.9). Moreover, the weight loss also positively affected several health measures, such as blood glucose level, body fat percentage, and blood pressure.

CONCLUSION

A reduction of ≥5 kg or 5% of body weight over a 30-month period reduces the risk for the onset of radiographic knee OA in middle-aged overweight and obese women. Because of the slow progression of the disease, a longer followup period will be necessary before the number of prevented cases of knee OA by moderate weight loss becomes clinically more relevant.

Long-term effects of a randomized, controlled, tailor-made weight-loss intervention in primary care on the health and lifestyle of overweight and obese women

BACKGROUND

Maintenance of weight loss after a diet and exercise intervention is often low. Moreover, short follow-up periods and high attrition rates often impede translation of study results to clinical practice.

OBJECTIVE

The present study evaluated the long-term effectiveness of a randomized, tailor-made lifestyle intervention, consisting of diet and exercise, on the health and lifestyle of overweight, middle-aged women in primary care.

DESIGN

The intervention was part of a randomized controlled trial on the prevention of knee osteoarthritis [PROOF (PRevention of knee Osteoarthritis in Overweight Females) study]. The intervention lasted 2.5 y and consisted of visits to the dietitian and participation in physical activity classes, supervised by a physiotherapist. The outcome of main interest of the present study was weight change (in kg) 6-7 y after randomization. Additionally, the intervention's effect on change in physical activity was investigated.

RESULTS

After 6 mo, weight loss was significantly higher in the intervention group (adjusted difference: 1.34 kg; 95% CI: 0.46, 2.22 kg). Over time, this difference decreased and became nonsignificant after 24 mo. Per-protocol analyses showed similar results. After 6 mo, change in physical activity was significantly higher in the intervention group (15.2%; 95% CI: 28.6%, 1.7%). Over time, this difference increased up to 29.8% (95% CI: 2.3%, 57.2%) after 6.6 y of follow-up. Per-protocol analyses showed no significant differences in change in physical activity.

CONCLUSIONS

A long-lasting intervention effect on change in physical activity was found, which increased over time. For weight change, smaller differences were found, which decreased over time. In future research, greater intervention effects on weight change are expected when higher compliance rates can be reached. The present study provides important recommendations for future research. The PROOF study was registered at http://www.isrctn.com as ISRCTN42823086.

Reducing progression of knee OA features assessed by MRI in overweight and obese women: secondary outcomes of a preventive RCT

OBJECTIVE

To evaluate the preventive effects of a randomized controlled trial on progression of Magnetic Resonance Imaging (MRI) features of knee osteoarthritis (OA) in overweight and obese women.

DESIGN

In a 2 × 2 factorial design, 2.5 years effects of a diet and exercise program and of glucosamine sulphate (double-blind, placebo-controlled) were evaluated in 407 middle-aged women with body mass index (BMI) ≥ 27 kg/m(2) without clinical signs of knee OA at baseline (ISRCTN 42823086). MRIs were scored with the MRI Osteoarthritis Knee Score (MOAKS). Progression was defined for bone marrow lesions (BMLs), cartilage defects, osteophytes, meniscal abnormalities and meniscal extrusion. Analyses on knee level were performed over the four intervention groups using adjusted Generalized Estimating Equations (GEE).

RESULTS

687 knees of 347 women with mean age 55.7 years (±3.2 SD) and mean BMI 32.3 kg/m(2) (±4.2 SD) were analyzed. Baseline prevalence was 64% for BMLs, 70% for cartilage defects, 24% for osteophytes, 66% for meniscal abnormalities and 52% for meniscal extrusions. The diet and exercise program + placebo intervention showed significantly less progression of meniscal extrusion compared to placebo only (12% vs 22%, OR 0.50, 95% CI [0.27-0.92]). The interventions did not result in significant differences on other OA MRI features.

CONCLUSIONS

In subjects at high risk for future knee OA development, a diet and exercise program, glucosamine sulphate and their combination showed small and mainly non-significant effects on the progression of OA MRI features. Only progression of meniscal extrusion was significantly diminished by the diet and exercise program.

Fibulin-3 fragments are prognostic biomarkers of osteoarthritis incidence in overweight and obese women

OBJECTIVE

To determine the association between three fibulin-3 peptides and the incidence of radiographic and clinical knee osteoarthritis (OA).

DESIGN

Women between 50 and 60 years, with a BMI ≥27 kg/m(2), free of knee OA, were recruited. Using binary logistic regression, the association between baseline concentration of serum fibulin (Fib)3-1, Fib3-2 and Fib3-3 and incidence of clinical and radiographic knee OA after 30 months of follow-up was evaluated.

RESULTS

Baseline and follow-up measurements were available for 241 women with a mean age of 55.9 ± 3.2 years and mean BMI of 31.7 ± 3.6 kg/m(2). None of the concentrations of the three Fib3 epitopes were associated with the incidence of medial or lateral joint space narrowing (JSN) ≥1.0 mm or the incidence of Kellgren & Lawrence (K&L) grade ≥2 after 30 months. All three Fib3 epitopes were associated with the incidence of the clinical and radiographic ACR-criteria and Fib3-1 and Fib3-3 also with chronic pain at follow-up. When adjusted for the other Fib3 peptide concentrations, only Fib3-1 was significantly associated to the incidence of the American College of Rheumatology (ACR)-criteria (OR 3.2 [1.2-8.7]) and chronic pain at follow-up (OR 3.0 [1.2-7.7]).

CONCLUSIONS

Baseline fibulin-3 concentrations are associated with the incidence of clinical knee OA among middle-aged overweight and obese women. Therewith, they meet the criteria of a prognostic biomarker according to the BIPED biomarker classification for OA. Further validation of the fibulin-3 epitopes seems warranted in order to better distinguish subgroups of individuals at increased risk for knee OA development.

Prevention of knee osteoarthritis in overweight females: the first preventive randomized controlled trial in osteoarthritis

BACKGROUND

With accumulating knowledge on osteoarthritis development, the next step is to focus on possibilities for primary prevention.

METHODS

In a 2 × 2 factorial design, the effects of a diet-and-exercise program and of oral glucosamine sulfate (double blind and placebo-controlled) on the incidence of knee osteoarthritis were evaluated in a high-risk group of 407 middle-aged women with a body mass index ≥ 27 kg/m(2) without clinical signs of knee osteoarthritis at baseline (ISRCTN 42823086). Primary outcome was the incidence of knee osteoarthritis, defined as Kellgren & Lawrence grade ≥ 2, joint space narrowing of ≥ 1.0 mm, or clinical knee osteoarthritis (clinical and radiographic American College of Rheumatology criteria) after 2.5 years.

RESULTS

After 2.5 years, only 10% of all subjects were lost to follow-up, and 17% of all knees showed incident knee osteoarthritis. Accounting for the significant interaction between the interventions, no significant main effect of either intervention was found. Independently, both interventions alone showed indications of reduced knee osteoarthritis incidence (odds ratio [OR] 0.69; 95% CI, 0.39-1.21 for the diet-and-exercise program and OR 0.60; 95% CI, 0.31-1.12 for the glucosamine intervention). These effects were neutralized in subjects receiving both interventions (OR 0.97; 95% CI, 0.55-1.71).

CONCLUSIONS

No significant main effects of the diet-and-exercise program and of glucosamine sulfate were found on incident knee osteoarthritis. Nevertheless, this trial provides valuable insights for future trial design for preventive osteoarthritis studies.

Behavioral treatment of obesity in patients encountered in primary care settings: a systematic review

IMPORTANCE

In 2011, the Centers for Medicare & Medicaid Services (CMS) approved intensive behavioral weight loss counseling for approximately 14 face-to-face, 10- to 15-minute sessions over 6 months for obese beneficiaries in primary care settings, when delivered by physicians and other CMS-defined primary care practitioners.

OBJECTIVE

To conduct a systematic review of behavioral counseling for overweight and obese patients recruited from primary care, as delivered by primary care practitioners working alone or with trained interventionists (eg, medical assistants, registered dietitians), or by trained interventionists working independently.

EVIDENCE REVIEW

We searched PubMed, CINAHL, and EMBASE for randomized controlled trials published between January 1980 and June 2014 that recruited overweight and obese patients from primary care; provided behavioral counseling (ie, diet, exercise, and behavioral therapy) for at least 3 months, with at least 6 months of postrandomization follow-up; included at least 15 participants per treatment group and objectively measured weights; and had a comparator, an intention-to-treat analysis, and attrition of less than 30% at 1 year or less than 40% at longer follow-up.

FINDINGS

Review of 3304 abstracts yielded 12 trials, involving 3893 participants, that met inclusion-exclusion criteria and prespecified quality ratings. No studies were found in which primary care practitioners delivered counseling that followed the CMS guidelines. Mean 6-month weight changes from baseline in the intervention groups ranged from a loss of 0.3 kg to 6.6 kg. In the control group, mean change ranged from a gain of 0.9 kg to a loss of 2.0 kg. Weight loss in both groups generally declined with longer follow-up (12-24 months). Interventions that prescribed both reduced energy intake (eg, ≥ 500 kcal/d) and increased physical activity (eg, ≥150 minutes a week of walking), with traditional behavioral therapy, generally produced larger weight loss than interventions without all 3 specific components. In the former trials, more treatment sessions, delivered in person or by telephone by trained interventionists, were associated with greater mean weight loss and likelihood of patients losing 5% or more of baseline weight.

CONCLUSIONS AND RELEVANCE

Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on primary care practitioners providing such care. The present findings suggest that a range of trained interventionists, who deliver counseling in person or by telephone, could be considered for treating overweight or obesity in patients encountered in primary care settings.

Latent class growth analysis successfully identified subgroups of participants during a weight loss intervention trial

INTRODUCTION

Weight loss interventions often present small mean weight changes over time, despite the fact that a substantial proportion of the participants lost more weight. This effect is often leveled out by the substantial proportion of participants who gained weight during the trial. The aim of this study is to identify and describe distinct subgroups of participants with different weight change trajectories during and after a weight loss intervention.

METHODS

We used data from a weight loss intervention that was part of a randomized controlled trial on the preventive effect of a tailor-made weight loss intervention and oral glucosamine sulfate on the incidence of knee osteoarthritis in 407 overweight women aged 50 to 60 years. Latent class growth analysis (LCGA) was used to identify subgroups of participants with different weight change trajectories over time.

RESULTS

Using LCGA, we identified three subgroups with different trajectories of weight change, one large group (n = 298) with almost no change over time, and two smaller groups (both n = 48), of which one represents participants who steadily gained weight over time, whereas the other represents participants who steadily lost weight over time. Participants that had relatively low body weight around their 40th year of life and that gained weight in the year preceding the study were most likely to belong to the group that lost weight.

CONCLUSION

LCGA was a suitable method to identify three distinct groups of participants with different trajectories of weight change. Low body weight at age 40 and weight gain in the year preceding the study were associated with a higher chance of membership of the group that lost weight. It seems weight loss that occurred during this weight loss intervention was mostly recently gained weight.

Malalignment: a possible target for prevention of incident knee osteoarthritis in overweight and obese women

OBJECTIVES

The present study aims to investigate the associations between malalignment and incident knee OA after 2.5 years in a high-risk group of 333 middle-aged overweight women (BMI ≥ 27 kg/m(2)) free of clinical and radiological knee OA at baseline.

METHODS

The primary outcome measure was the incidence of knee OA, defined as the incidence of radiographic knee OA (Kellgren and Lawrence grade ≥2), clinical knee OA (ACR criteria) or medial or lateral joint space narrowing (≥1.0 mm). Using generalized estimating equations, associations between valgus and varus alignment (compared with neutrally aligned knees) and the primary outcome measure and all its items separately were studied.

RESULTS

Neither varus- nor valgus-aligned knees had a significantly increased risk for incident knee OA according to the primary outcome measure. A significantly increased risk for the development of radiographic knee OA was found for varus-aligned knees [odds ratio (OR) 3.3, 95% CI 1.5, 7.3]. Valgus-aligned knees showed a borderline increased OR (2.8, 95% CI 1.0, 8.0) for the development of radiographic knee OA. No statistically significant effects were found for varus and valgus alignment on the incidence of clinical knee OA or medial or lateral joint space narrowing.

CONCLUSION

Since this study was performed in a true target population, current data suggest that malalignment might be a target for the prevention of radiographic knee OA in overweight and obese women.